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{\*\generator Adobe Acrobat Exchange-Pro 7.0}{\info{\title Microsoft Word - Document1}{\author jon}{\creatim\yr2005\mo4\dy20\hr20\min47\sec40}{\revtim\yr2005\mo4\dy20\hr20\min47\sec40}{\id1241500}}\pard\plain\ql\f0\fs24\cf0 \paperh15840\paperw12240\margt1060
\margr2140\margl920\sectd\sbknone\pard\plain\pghsxn15840\pgwsxn12240\margtsxn1060\margrsxn2140\marglsxn920\pard\s1\sa805\b\fs22 PLAYER MEDICAL INFORMATION SHEET \b0\ulnone\strike0\par\pard\s1\sa805\f1 Name: _____________________________________________________ 
\ulnone\strike0\par\pard\s2\sa533 Date of birth: Day ______ Month ______ Year ________ \ulnone\strike0\par\pard\s3\s2\sa533\sl533\slmult0 Address: ______________________________________________________ Postal Code: ___________________ Telephone: _____________________
_ Mother\rquote s Name: _____________________ Father\rquote s Name: ____________________ Business Telephone Numbers: Mother ____________ Father\rquote s Name: ____________ \ulnone\strike0\par\sect\sbknone\sectd\pard\plain\sectd\sbknone\pard\plain\pghsxn15840\pgwsxn12240\margtsxn1060\margrsxn2140\marglsxn920\par\pard\s3\s2\sa533\sl533\slmult0\b\fs22 
Person to contact in case of accident or emergency, if parents are not available. \b0\ulnone\strike0\par\pard\s3\sl533\slmult0\f1 Name: _________________________________ Telephone: ____________________ Address: ______________________________________________________________ Doctor\rquote s Name: __________________________ Telephone: ____________________ Dentist\rquote s Name: __________________________ Telephone: ____________________ 
\ulnone\strike0\par\sect\sbknone\sectd\pard\plain\sectd\sbknone\pard\plain\pghsxn15840\pgwsxn12240\margtsxn1060\margrsxn3420\marglsxn920\par\pard\s3\s2\sa533\sl533\slmult0\b\fs22 Please circle the appropriate response below pertaining to your child \b0\ulnone\strike0\par\pard\s3\sl533\slmult0\f1 
Yes No Previous history of concussions Yes No Fainting episodes during exercise Yes No Epileptic Yes No Wears glasses Yes No Are lenses shatterproof? Yes No Wears contact lenses Yes No Wears dental appliance Yes No Hearing problem Yes No Asthma Yes No Trouble breathing during exercise Yes No Heart Condition Yes No Diabetic Yes No Has had an illness lasting more than a week in the past year Yes No Medication Yes No Allergies 
\ulnone\strike0\par\sect\sbknone\sectd\pard\plain\sectd\sbknone\pard\plain\pghsxn15840\pgwsxn12240\margtsxn1060\margrsxn600\marglsxn920\par\pard\s3\sl533\slmult0\b\fs22 H o c k e yT r a i n e r s C e r t i f i c a t i o n P r o g r a m \b0\ulnone\strike0\par\pard\s3\sa277\sl533\slmult0\f1 
Yes No Wears a medic alert bracelet or necklace. Yes No Does your child have any health problem that would interfere with participation on a hockey   \ulnone\strike0\par\pard\s1\fi798\sa805\sl533\slmult0              team? Yes No Surgery in the last year. Yes No Has been in hospital in the last year. Yes No Has had injuries requiring medical attention in the past year. Yes No Presently injured. 
\ulnone\strike0\par\sect\sbknone\sectd\pard\plain\sectd\sbknone\pard\plain\pghsxn15840\pgwsxn12240\margtsxn1060\margrsxn600\marglsxn920\par\pard\s4\sl256\slmult0\b\fs22 Please give details below if you answered "Yes" to any of the above items. Use separate sheet if necessary 
\b0\ulnone\strike0\par\pard\s2\ri1600\sa533\sl533\slmult0\f1 Medications: __________________________________________________________ Allergies: _____________________________________________________________ Medical conditions: _____________________________________________________ Recent Injuries: ________________________________________________________ Last Tetanus Shot:______________________________________________________ Any information not covered above:________________________________________ 
\ulnone\strike0\par\pard\s3\s5\sa278\sl533\slmult0 Date of last complete physical examination: __________________________________ \ulnone\strike0\par\pard\s5\ri63\sa278\sl256\slmult0 * Any medical condition or injury problem should be checked by your physician before participating in a hockey program. 
\ulnone\strike0\par\pard\s5\ri418\sa278\sl256\slmult0 I understand that it is my responsibility to keep the team management advised of any change in the above information as soon as possible and that in the event no one can be contacted, team management will take my child to hospital/M.D. if deemed necessary. 
\ulnone\strike0\par\pard\s5\ri1018\sa278\sl256\slmult0 I hereby authorize the physician and nursing staff to undertake examination investigation and necessary treatment of my child. \ulnone\strike0\par\pard\s4\s2\sa533\sl256\slmult0 I also authorize release of information to appropriate people (coach, physician) as deemed necessary. 
\ulnone\strike0\par\pard\s4\sl256\slmult0 Date: ____________ Signature of Parent or Guardian: __________________ \ulnone\strike0\sect\sbknone }